Liar, Liar … Well, Healthcare Pants on Fire

So, we've been told over and over again that under the healthcare reform plans currently defended and pushed by the President and Congress that we can keep what we've got if we like it. No one will take your health insurance bennies away. Not under our employer-based, for-profit system.

Well, tell that to the latest batch of employees in Chicago to have their insurance benefits cut right out from under them – they sure didn't get to keep what they had.

The workers at SK Tools had no choice. Their health insurance benefits were cancelled. Sick family member? Too damn bad. Need a doctor. Tough luck. The company representatives say the recession has hurt them, and they have no choice. The company is also asking for 20 percent cuts in hourly wages. Wow.

Now, the workers have voted to strike. And there will perhaps be some resolution for this bunch of employees. Folks will cry out, perhaps even President Obama will step in, and this situation will probably get resolved – though folks will suffer in the interim.

But the larger issue remains. Just how gullible are we when we trust that any private company will be forced to keep any benefit plan it chooses not to keep?

Employers will still be able to change up healthcare plans to meet the company's needs – and if that means you have to see another doctor or pay a higher co-pay or drive to a more distant in-network provider, that will not be your decision. And health insurance companies will still be able to change their provider lists and covered services and all sorts of other things without any input from policyholders.

So, America, it just isn't true that you can keep what you have if you like it when it comes to private, employer-based healthcare benefits. It's a big, fat lie. And the company noted in the article above provides but one example. There will be many more.

The House bill on healthcare reform, the Senate plan for healthcare reform and the President's plan for healthcare reform – none of these actually guarantee that you can keep what you have if you like it, because tomorrow your employer or your insurance company may change what you like to suit their bottom line. That's the truth.

If this big lie about healthcare reform rolls off their messaging engines like melting butter on a warm slice of bread, what else do you suppose they are lying about? Come on. Get real. We won't have what we want in terms of truly having the freedom to choose and keep or change our doctors, our providers and our own treatments until we break free from the lies and produce reform that guarantees a progressively financed, single high-quality standard of care for everybody. Everybody in, nobody out.

Then you can keep what you like. Your choices. Your decisions. Your health. Your healthcare. Your money. Period.

It's not just the right-wing selling myths in this discussion. We need to admit that and work to be as honest as we can. Too many lives depend on this. There will be no death panels to order Grandma's demise, but there are also no guarantees that you can keep what you have if you like it under this system. Both things are lies.

We can provide one another the healthcare security that we're being misled to believe is in the current reform plans. But we will have to help our fellow Americans to understand that a publicly financed, privately delivered healthcare system – like Medicare – for all of us is the most reasoned, most economical and most freedom-protecting choice.

And that's the truth.

Donna Smith is a community organizer for the California Nurses Association and National Co-Chair for the Progressive Democrats of America Healthcare Not Warfare campaign.

Town hall focuses on health care system's ills

PETERSBURG - Opponents of health care reform have been trying to scare the public with stories of death panels and government bureaucrats rationing health care, but the really frightening prospect would be to leave the system unchanged, according to a group of reform advocates who held a town hall here Wednesday night.

Tri-City Medical Town Hall held a panel discussion at Union Station billed as "What Health Care Reform Should Be," but by far the largest part of the talk focused on why they believe the current system needs to be changed.

The most dramatic presentation was that of Cynthia Wilson, a teacher at the Appomattox Regional Governor's School who commanded the attention of the audience of about 50 people as she recounted her ongoing battles with breast cancer - and her health insurer.

Wilson described long waits on the telephone as she tried to get approval for tests and treatments; of seemingly capricious decisions such as approving payment for a $400 pressure sleeve but denying it for a $100 model; of being told she shouldn't have an important test because a positive result might prompt her insurer to cancel her policy.

Some legislators have said they oppose reform because they say " 'We don't want to put a government bureaucrat between you and your medical treatment,' " Wilson said. "Well, I've had constant battles with corporate bureaucrats."

Andrea Miller, an emergency operations trainer and former Democratic candidate for Congress in the Fourth District, noted that insurers "are trying to make mastectomies an outpatient procedure." She noted that a bill has been introduced in the House of Representatives, the Breast Cancer Patient Protection Act, that would require doctors to keep women in the hospital for at least 48 hours after a mastectomy.

Dr. Lerla Joseph, a Charles City internist, echoed some of President Obama's recent presentations by directly addressing what she called the "myths" that opponents have spread about reform proposals. But she also described some of the problems that the current system creates for doctors as well as patients.

Health care "is costing us too much, and not enough people are covered," she said. The existing system is "convoluted" and "not fiscally sustainable." Some opponents have predicted that reform "will bankrupt America, but it is bankrupting individuals today," she said.

The current system also is a burden to business, Joseph added, noting that high health care costs were a major factor in the bankruptcy of General Motors earlier this year.

The system is so complicated that many doctors themselves don't fully understand it, said Dr. Stephen Vaughan of Petersburg-based Convenient Health Care Inc. "It wasn't until my father was diagnosed with prostate cancer - terminal - that I understood how complicated Medicare is," he said.

"We need to make some serious adjustments," Vaughan said. "We have to modify a lot of things."

Introducing The FAIR Health Plan

Introducing The FAIR Health Plan (Federal Act Insurance Restructured)

Nearly everyone in America can agree that the current healthcare system is broken. Now we have a real solution, the Federal Act Insurance Restructure (FAIR) Health Plan, a functional and cost-effective healthcare system. The FAIR Health Plan is designed to meet all of the strategic goals that the American people deserve. It is largely based on successful healthcare systems that are proven sustainable over the long term.

The FAIR Health Plan allows the uninsured to have access to healthcare in a way that is very cost effective, and saves over $200 billion in its first year in Medicaid expenditures alone, without an adverse effect to the care provided. Compared to Medicaid today, which is projected to increase annually at the rate of 7.9%, the FAIR Health Plan is estimated to save over $3 trillion over its first 10 years, yet provides coverage for all Americans under the age of 65.

The plan gives maximum flexibility to American people, allowing them to see any doctor at any time without the need to get a referral. It encourages people to only use the healthcare system when they really need it by implementing a yearly Utilization Fee, which will discourage overuse and keep premiums low. The government has no need to raise taxes as the plan pays for itself, and covers everyone that wants coverage, regardless of pre-existing conditions. The FAIR Health Plan implements a 7% cap on administration costs, the same as existing Federal Health Plans.

As for doctors, the FAIR Health Plan pays them for 100% of the services they provide, instead of the all-too typical 50% reimbursement that they receive from many insurance companies. Also, with its digital payment system, medical providers are compensated in days instead of months, removing the need for costly billing and collection agencies.

This innovative and proven solution to our healthcare crisis needs the American public to go online to http://www.fairhealthplan.org, read over the facts and encourage our law makers to consider this option before moving forward. The time has come for Americans to take back control of our health care, and the FAIR Health Plan is the solution.

Sen. Edward M. Kennedy -- Health Care Champion -- Dies

Sen. Edward M. Kennedy had a hand in nearly every piece of health care legislation that moved through Congress during his eight-term Senate tenure. He died Tuesday night of brain cancer at age 77.

NPR: "Kennedy had hoped to be at the center of this year's debate over a landmark bill remaking the American health care system. Even after suffering a seizure on Inauguration Day, he again returned to work. He took part in early legislative skirmishes on behalf of the new president - whose nomination for the White House he had given a boost with an early endorsement. But as his illness advanced, Kennedy was unable to take the gavel when the Senate committee he chaired took up the bill in June" (Elving and Naylor, 8/26).

The Boston Globe recounts that Kennedy's health care work was marked by his return to the Senate in December 1969 after his car accident at Chappaquiddick, which killed a former aide to his brother Robert. In that year he "began a long campaign 'to move now to establish a comprehensive national health care insurance program.'"

The Globe also recounts Kennedy's differences with President Carter over health care policy: "The ideological divide between the two was profound. Senator Kennedy thought Carter's health care programs were timid."

Last summer, "(d)espite his illness, Senator Kennedy made a forceful appearance at the Democratic convention in Denver, exhorting his party to victory and declaring that the fight for universal health insurance had been 'the cause of my life.' He pursued that cause vigorously, even as his health declined; when members of Obama's administration questioned the president's decision to spend so much political capital on the seemingly intractable issue, Obama reportedly replied, 'I promised Teddy'" (Nolan, 8/26).

The New York Times: "While Mr. Kennedy had been physically absent from the capital in recent months, his presence had been deeply felt as Congress weighed the most sweeping revisions to America's health care system in decades. … He built federal support for community health care centers, increased cancer research financing and helped create the Meals on Wheels program. He was a major proponent of a health and nutrition program for pregnant women and infants." He was among then-President Bill Clinton's and Hillary Clinton's "strongest allies in their failed 1994 effort to enact national health insurance, a measure the senator had been pushing, in one form or another, since 1969." In 1997, he teamed up with Senator Orrin Hatch, R-Utah to help "enact a landmark health care program for children in low-income families, a program now known as the State Children's Health Insurance Program, or S-Chip." He also "helped win enactment of the Medicare prescription drug benefit, one of the largest expansions of government health aid ever" (Broder, 8/26).

The Washington Post: "His legislation resulted in access to health care for millions of people and funded cures for diseases that afflicted people around the world. He was a longtime advocate for universal health care and was instrumental in promoting biomedical research, as well as AIDS research and treatment." For example, he was "a leader in the passage of the Americans With Disabilities Act of 1990 and the 1996 Kennedy-Kassebaum Bill" which provided employees with the ability to keep health insurance after leaving a job.

"Health care reform is 'a defining issue for our society,' Kennedy told fellow senators during a 1994 debate. 'Do we really care about our fellow citizens?' It was a question he asked countless times, in one form or another, during his long Senate career. He faced opposition from most Republicans -- and more than a few Democrats -- who insisted that Kennedy's proposals for universal health care amounted to socialized medicine that would lead to bureaucratic sclerosis and budget-breaking costs and inefficiencies."

He first became involved in health care issues in 1966 "after he became aware of the difficulties facing Boston public-housing residents who had to rely on the city's teaching hospitals. Although they lived only four miles from the hospitals, it took them up to five hours to get there and back on buses and subways, including the time it took to wait in an emergency room" (Holley, 8/26).

The Wall Street Journal: "Mr. Kennedy died with one of his lifelong goals, universal health care, tantalizingly within reach yet struggling on Capitol Hill. Some advocates have said his absence has hurt the chances for legislation, and hope Mr. Kennedy's passing will give new momentum and emotional force to his favored cause. … Mr. Kennedy's final months were marked by the poignancy of a man who had fought his whole career for universal health care facing his last window of opportunity to accomplish it, even while engaging in his own devastating health battle" (Bendavid, 8/26).

USA Today: "Congress will make Kennedy's unfulfilled goal his legacy, House Speaker Nancy Pelosi, D-Calif., predicted in a statement early today. 'Ted Kennedy's dream of quality health care for all Americans will be made real this year because of his leadership and his inspiration'" (Kiely, 8/26).

President Obama called Kennedy "the greatest senator of our time," The Associated Press reports. Kennedy was key in getting Obama elected, Obama also said. (Kesten, 8/26).

Health-reform advocates host meeting

A local group that supports creation of a government-administered "single-payer" health care financing system will hold a town hall meeting here this week.

Tri-City Medical Town Hall has scheduled a presentation and discussion on "What Health Care Reform Should Be" at 7 p.m. Wednesday at Union Station. Panelists for the discussion are:

- Dr. Lerla Joseph, a Charles City internist and member of the advisory board of health care advocacy group United Virginia.

- Dr. Stephen Vaughan, Convenient Health Care Inc., Petersburg.

- Dr. William Ferguson Reid, a former member of the House of Delegates and a member of United Virginia and two other groups that advocate a single-payer system, Physicians for a National Health Program and Healthcare Now.

The discussion will be moderated by Andrea Miller, an emergency operations trainer and former Democratic candidate for Congress in the Fourth District.

According to Healthcare Now, "Single-payer is a term used to describe a type of financing system. It refers to one entity acting as administrator, or 'payer.' In the case of health care, a single-payer system would be set up such that one entity - a government-run organization - would collect all health care fees and pay out all health care costs."

Such a system, according to the advocacy group, will help reduce the cost of health care. "In a single-payer system, all hospitals, doctors and other health care providers would bill one entity for their services," the group noted. "This alone reduces administrative waste greatly and saves money, which can be used to provide care and insurance to those who currently don't have it."

The groups sponsoring the town hall meeting, which also include the California Nurses Association and Progressive Democrats of America, are supporting legislation introduced this year in the House of Representatives, the U.S. National Health Care Act or Expanded and Improved Medicare for All Act (H.R. 676). The bill would expand the existing government-run Medicare system to provide health insurance coverage for all U.S. residents.

Miller said the proposal would differ from a Canadian- or European-style national health system, in which health services are provided by a government agency, because it would be "publicly funded but privately delivered" - that is, private businesses would provide the services and treatments, and would be reimbursed by the government, as is currently done under Medicare.

The bill also would include prescription drug coverage in which prices are "fully negotiated" as they are under Department of Veterans Affairs health benefits programs, Miller said.

The single-payer proposal differs significantly from the widely publicized America's Affordable Health Choices Act of 2009 (H.R. 3200), which includes a proposal that would create a government-run health insurance provider to be offered as one option alongside private insurance companies in a "Health Insurance Exchange" program.

Under that plan, which generally reflects the Obama administration's preferences, anyone who lacks health coverage could pick an insurance provider from among those offered through the exchange, including the government-run or "public" option. Different providers would offer different levels of benefits at different prices.

Fear Mongering Abounds In Health Debate

"What many people say they fear most from an overhaul of the health care system [is] the prospect of the federal government's limiting the medical care they receive," the New York Times reports. Policy experts say people are right to worry about health care costs, but this fear of rationing is unrealistic. "[T]here is nothing in the current proposals in Washington to suggest that the country is likely to embark on a system of medical rationing anytime soon," the Times reports (Abelson, 8/24).

A variation of this fear stems from proposals that would affect end-of-life care. A Veterans Affairs guide to writing living wills, "Your Life, Your Choices," spurred controversy last week when a former Bush administration official dinged it in a Wall Street Journal op-ed, NPR reports. The document asks veterans to choose in advance when they would say their lives are no longer worth continuing, based on criteria like relying on a wheelchair, living in a nursing home or being sad all the time. Jim Towey, the former leader of the White House Office of Faith-Based Initiatives, said, "That makes them feel their life is a burden not a gift." NPR notes that Dave Autry, a spokesman for Disabled Veterans of America, said "It's a tempest in a teapot as far as I'm concerned, personally," and adds: "He says although health care is on the minds of veterans at the convention, the VA guide has gotten almost no attention. And then, mainly from veterans who worry that it's being used to undermine attempts to change health care" (Shapiro, 8/24).

To critics of reform, Ezekiel Emanuel, a bioethicist and physician who advises the White House on health care issues, has become the object of many of these fears, the New York Times reports. Betsy McCaughey, the former lieutenant governor of New York, called him a "deadly" doctor who seeks to restrict care for the disabled, "a false assertion" gleaned from quoting his writing "out of context" and then repeated on the House floor by Rep. Michele Bachmann, R-Minn. However, the Times reports, "The level of vitriol against him has led even some conservative opponents to defend Dr. Emanuel while expressing concern that it is overtaking what they say are more vital real-world critiques" (Rutenberg, 8/24).

Obama's Invocation Of Faith

Obama's Invocation Of Faith To Promote Health Reform 'Refreshing,' Opinion Piece Says

"The fight over health care took the most interesting turn last week" when President Obama "briefly switched from wonkish frippery about bending cost curves to speaking of faith," columnist Jonah Goldberg writes in a Los Angeles Times opinion piece. This "would be an easy opportunity to call attention, once again, to the double standards applied to Obama," Goldberg writes, adding, "When President George W. Bush invoked God as his inspiration, many liberals lamented the shattering of the wall between church and state by our theocrat in chief. When Obama does likewise, it's inspiring, spiritual leadership." Goldberg writes that he finds Obama's invocation of faith "refreshing" because "[o]f all of the silly arguments that have been passed off as deeply profound in American politics, the notion that politicians can't 'impose' their personal morality on others has to top the list."

Goldberg writes, "We have abortion politics in general, and former New York Gov. Mario Cuomo (D) in particular, to thank for that." In 1984, Cuomo "gave his famous address at Notre Dame in which he laid out the notion that a politician can be 'personally opposed' to abortion but should refuse to translate that conviction into public policy," Goldberg writes. He continues, "As political rhetoric, the speech was compelling," but "[a]s a serious philosophical, theological or moral argument, it was a terrible mess. For instance, Cuomo found inspiration in the Catholic Church's relative silence on American slavery as justification for keeping religion out of the abortion debate." He adds, "Never mind that abolition was the most religious of political movements."

Goldberg writes that Sen. John Kerry (D-Mass.) "captured the inherent contradictions of Cuomo-ism nicely" during a 2004 presidential debate. Kerry said that his faith spurred him to address poverty, environmental issues and other topics. However, Kerry added that when it came to abortion, "What is an article of faith for me is not something that I can legislate on somebody who doesn't share that article of faith."

In recent years, however, "Democratic rhetoric has been changing, for several reasons," Goldberg writes. He adds that "many voters are put off by such double-talk. Another reason is that many smart liberals have noticed that some religious Americans are more activist on economic and environmental issues but are turned off by what they perceive as pugnacious secularism."

According to Goldberg, "Politics has always been a contest of values, and religion remains the chief source of those values." He adds, "Our political discourse has long been cheapened by the canard that only conservatives try to use the state to impose a religiously informed moral vision, while liberals are guided by science, reason and logic as well as some secular conception of decency and compassion." Goldberg concludes, "No party has a monopoly on such resources, and it's about time we all recognize that" (Goldberg, Los Angeles Times, 8/25).

Young Obama Supporters Missing From Health Reform Debate

Obama's tech-savvy young activists, who were instrumental in getting him elected, are not as active on health care reform, a gap Obama will have to fix if he is to regain momentum for his top domestic priority, The Associated Press reports. "Younger people are generally healthier and rely on less medical care, particularly young working men who make up the largest group that goes voluntarily without health insurance. They also are less likely to be as vocal at contentious town halls; many are either working or in school during the daytime forums. "

In an effort to activate his base, "Obama talked up health care in an online town meeting last week with Organizing for America, the campaign operation reconstituted as the White House political arm."

"Democrats on Capitol Hill are taking up the challenge as well. Rep. Chris Van Hollen, D-Md., and other members of the party leadership planned to hold a news conference Wednesday in Washington to discuss the ways the plan would help young people. … But critics also point to a failure of Obama's message, saying that by focusing so intently on the concerns of senior citizens the White House may have lost the attention of younger voters" (Fouhy, 8/24).

Insurers Seek Savings By Offering Coverage For Care In Other Countries

More insurers are offering networks of doctors overseas and in other countries for their policyholders as a way to save money as lawmakers struggle with how to drive down costs, The Associated Press/USA Today reports.

"As Washington searches for ways to tame the country's escalating health care costs, more insurers are offering networks of surgeons and dentists in places like India and Costa Rica, where costs can be as much as 80% less than in America. Until recently, most Americans traveling abroad for cheaper non-emergency medical care were either uninsured or wealthy." But this profile is changing. "Now, they are more likely to be people covered by private insurers, which are looking to keep costs from spiraling out of control. The four largest commercial U.S. health insurers - with enrollments totaling nearly 100 million people - have either launched pilot programs offering overseas travel or explored it. Several smaller insurers and brokers also have introduced travel options for hundreds of employers around the country" (Murphy, 8/23).

Health Reform Fact Checks Fall Short

Health Reform Fact Checks Fall Short On Dispelling Angry Myths

A fact check of a dozen often-repeated claims by politicos and interest groups finds that the truth appears "to be taking a vacation," CQ Politics reports. Of the 12 claims, CQ concludes that only one is true, six are misleading and five are downright false. Among the false claims are those suggesting that the government plans to ration care, create a mandate for employers to enroll workers in the public plan, and require individuals to draft living wills that could lead to euthanasia, and that existing plans would not increase the federal deficit. The sole legitimate claim: individuals would have to pay a 2.5 percent income tax if they choose to go without insurance (McCarthy and Armstrong, 8/23).

News media have effectively dug into the legislation and issues of health reform rather than leaning on the "neutrality of quoting dueling antagonists. … But even when they reported the facts, they have had trouble influencing public opinion," writes the Washington Post's media columnist, Howard Kurtz. Many of the claims made by political operators and activists have been perpetuated despite similar articles that attempt to debunk them. "[T]he healthy dose of coverage has largely failed to dispel many of the half-truths and exaggerations surrounding the debate." Some of the outrage propelling mistruths is "unfocussed or simply" anti-President Obama (Kurtz, 8/24).

One reason news reports that attempt to debunk and reveal aspects of the health reform debate so often fall flat, allowing claims like the suggestion that reform would create "death panels" to resonate, is that the anger of reform critics reaches beyond health care. Conversations with white voters "suggest more is brewing in the nation's troubled soul than a debate over the mechanics of health care reform," the San Jose Mecury News reports. "The recession has savaged whites and middle-aged men to a degree unseen in most people's lifetimes. And that has helped make many in those groups desperately, angrily anxious about change."

"'Some of it is not about health care, let's face it,' Richard Czik, former vice president of governmental affairs for the National Association of Evangelicals, told the Mercury News. 'Some of it has to be about an obvious rejection of Obama's legitimacy as president. You wouldn't get this anger, represented by the hate-mongering you see. Some of it is directed against the president, with some pretty deep-seated attitudes'" (Swift and Richman, 8/22).

Insurance Industry May Benefit From Reform

Insurance Industry May Benefit From Reform, Employees Attend Town Halls To Counter Criticism

"Lashed by liberals and threatened with more government regulation, the insurance industry nevertheless rallied its lobbying and grass-roots resources so successfully in the early stages of the healthcare overhaul deliberations that it is poised to reap a financial windfall," The Los Angeles Times reports. "The half-dozen leading overhaul proposals circulating in Congress would require all citizens to have health insurance, which would guarantee insurers tens of millions of new customers -- many of whom would get government subsidies to help pay the companies' premiums."

Linda Blumberg, a health policy analyst at the Urban Institute, says insurers "are going to have this very stable pool, they're going to have people getting subsidies to help them buy coverage...." Insurers have mobilized in opposition to the public option, lobbying on Capitol Hill, encouraging employees to speak out and launching local ad campaigns. "Recent support for the public option has declined, and the stock prices of health insurance firms have been rising."

Insurers have also had success in keeping benefits low in congressional proposals. "In May, the Senate Finance Committee discussed requiring that insurers reimburse at least 76% of policyholders' medical costs under their most affordable plans. Now the committee is considering setting that rate as low as 65%.... Most group health plans cover 80% to 90% or more of a policyholder's medical bills, according to a report by the Congressional Research Service" (Hamburger and Geiger, 8/24).

The Wall Street Journal reports that "the health-insurance industry is sending thousands of its employees to town-hall meetings and other forums during Congress's August recess to try to counter a tide of criticism directed at the insurers and remain a player -- and not an outsider -- in the debate over the future of the health-care system." Those employees are "armed with talking points about the need for bipartisan legislation and the unintended consequences of a government-run health plan to compete with private insurers," but have gone mostly under the radar so far.

Karen Ignagni, president and CEO of America's Health Insurance Plans, says the town halls are a chance "to strongly push back against charges that we have very high profits. … It's very important that our men and women... calmly provide the facts and for members of Congress to hear what these people do every day." An AHIP memo warns employees to expect harsh criticisms but not to yell at lawmakers. "'It is important not to take the bait,' it cautions" (Fuhrmans and Johnson, 8/24).

Comparison Between Different Countries

The Commonwealth Fund, in its annual survey, "Mirror, Mirror on the Wall", compares the performance of the health care systems in Australia, New Zealand, the United Kingdom, Germany, Canada and the U.S. Its 2007 study found that, although the U.S. system is the most expensive, it consistently under-performs compared to the other countries. One difference between the U.S. and the other countries in the study is that the U.S. is the only country without universal health insurance coverage.

Australia

The public health system is called Medicare. It ensures free universal access to hospital treatment and subsidized out-of-hospital medical treatment. It is funded by a 1.5% tax levy on all taxpayers, an extra 1% levy on high income earners, as well as general revenue.

The private health system is funded by a number of private health insurance organizations. The largest of these is Medibank Private, which is government-owned, but operates as a government business enterprise under the same regulatory regime as all other registered private health funds. The Coalition Howard government had announced that Medibank would be privatized if it won the 2007 election, however they were defeated by the Australian Labor Party under Kevin Rudd which had already pledged that it would remain in government ownership.

Some private health insurers are 'for profit' enterprises, and some are non-profit organizations such as HCF Health Insurance and GMHBA Health Insurance. Some have membership restricted to particular groups, but the majority have open membership. Membership to most health funds is now also available through comparison websites like money time and iSelect. These comparison sites operate on a commission-basis by agreement with their participating health funds.

Most aspects of private health insurance in Australia are regulated by the Private Health Insurance Act 2007.

The private health system in Australia operates on a "community rating" basis, whereby premiums do not vary solely because of a person's previous medical history, current state of health, or (generally speaking) their age (but see Lifetime Health Cover below). Balancing this are waiting periods, in particular for pre-existing conditions (usually referred to within the industry as PEA, which stands for "pre-existing ailment"). Funds are entitled to impose a waiting period of up to 12 months on benefits for any medical condition the signs and symptoms of which existed during the six months ending on the day the person first took out insurance. They are also entitled to impose a 12-month waiting period for benefits for treatment relating to an obstetric condition, and a 2-month waiting period for all other benefits when a person first takes out private insurance. Funds have the discretion to reduce or remove such waiting periods in individual cases. They are also free not to impose them to begin with, but this would place such a fund at risk of "adverse selection", attracting a disproportionate number of members from other funds, or from the pool of intending members who might otherwise have joined other funds. It would also attract people with existing medical conditions, who might not otherwise have taken out insurance at all because of the denial of benefits for 12 months due to the PEA Rule. The benefits paid out for these conditions would create pressure on premiums for all the fund's members, causing some to drop their membership, which would lead to further rises, and a vicious cycle would ensue.

There are a number of other matters about which funds are not permitted to discriminate between members in terms of premiums, benefits or membership - these include racial origin, religion, sex, sexual orientation, nature of employment, and leisure activities. Premiums for a fund's product that is sold in more than one state can vary from state to state, but not within the same state.

The Australian government has introduced a number of incentives to encourage adults to take out private hospital insurance. These include:

• Lifetime Health Cover: If a person has not taken out private hospital cover by the 1st July after their 31st birthday, then when (and if) they do so after this time, their premiums must include a loading of 2% per annum for each year they were without hospital cover. Thus, a person taking out private cover for the first time at age 40 will pay a 20 per cent loading. The loading is removed after 10 years of continuous hospital cover. The loading applies only to premiums for hospital cover, not to ancillary (extras) cover.

• Medicare Levy Surcharge: People whose taxable income is greater than a specified amount (currently $70,000 for singles and $140,000 for couples) and who do not have an adequate level of private hospital cover must pay a 1% surcharge on top of the standard 1.5% Medicare Levy. The rationale is that if the people in this income group are forced to pay more money one way or another, most would choose to purchase hospital insurance with it, with the possibility of a benefit in the event that they need private hospital treatment - rather than pay it in the form of extra tax as well as having to meet their own private hospital costs.
• The Australian government announced in May 2008 that it proposes to increase the thresholds, to $100,000 for singles and $150,000 for families. These changes require legislative approval. A bill to change the law has been introduced but was not passed by the Senate. An amended version was passed on 16 October 2008. There have been criticisms that the changes will cause many people to drop their private health insurance, causing a further burden on the public hospital system, and a rise in premiums for those who stay with the private system. Other commentators believe the effect will be minimal.

• Private Health Insurance Rebate: The government subsidises the premiums for all private health insurance cover, including hospital and ancillary (extras), by 30%, 35% or 40%, depending on age. The Rudd Government announced in May 2009 that as of July 2010, the Rebate would become means-tested, and offered on a sliding scale.

Canada

Most health insurance in Canada is administered by each province, under the Canada Health Act, which requires all people to have free access to basic health services. Collectively, the public provincial health insurance systems in Canada are frequently referred to as Medicare. Private health insurance is allowed, but the provincial governments allow it only for services that the public health plans do not cover; for example, semi-private or private rooms in hospitals and prescription drug plans. Canadians are free to use private insurance for elective medical services such as laser vision correction surgery, cosmetic surgery, and other non-basic medical procedures. Some 65% of Canadians have some form of supplementary private health insurance; many of them receive it through their employers. Private-sector services not paid for by the government account for nearly 30 percent of total health care spending.

In 2005, the Supreme Court of Quebec ruled, in Chaoulli v. Quebec, that the province's prohibition on private insurance for health care already insured by the provincial plan could constitute an infringement of the right to life and security if there were long wait times for treatment as happened in this case. Certain other provinces have legislation which financially discourages but does not forbid private health insurance in areas covered by the public plans. The ruling has not changed the overall pattern of health insurance across Canada but has spurred on attempts to tackle the core issues of supply and demand and the impact of wait times.

France

The French model of health insurance has been ranked by the World Health Organization as the best in the world, because it permits a high quality of care and nearly total patient freedom. The national system of health insurance was instituted in 1945, just after the end of the Second World War. It was a compromise between Gaullist and Communist representatives in the French parliament. The Conservative Gaullists were opposed to a state-run healthcare system, while the Communists were supportive of a complete nationalisation of health care along a British Beveridge model.

The resulting program is profession-based: all people working are required to pay a portion of their income to a health insurance fund, which mutualize the risk of illness, and which reimburses medical expenses at varying rates. Children and spouses of insured people are eligible for benefits, as well. Each fund is free to manage its own budget, and used to reimburse medical expenses at the rate it saw fit, however following a number of reforms in recent years, the majority of funds provide the same level of re-imbursement and benefits.

The government has two responsibilities in this system.

• The first government responsibility is the fixing of the rate at which medical expenses should be negotiated, and it does this in two ways: The Ministry of Health directly negotiates prices of medicine with the manufacturers, based on the average price of sale observed in neighboring countries. A board of doctors and experts decides if the medicine provides a valuable enough medical benefit to be reimbursed (note that most medicine is reimbursed, including homeopathy). In parallel, the government fixes the reimbursment rate for medical services: this means that a doctor is free to charge the fee that he wishes for a consultation or an examination, but the social security system will only reimburse it at a pre-set rate. These tariffs are set annually through negotiation with doctors' representative organisations.
• The second government responsibility is oversight of the health-insurance funds, to ensure that they are correctly managing the sums they receive, and to ensure oversight of the public hospital network.

Today, this system is more-or-less intact. All citizens and legal foreign residents of France are covered by one of these mandatory programs, which continue to be funded by worker participation. However, since 1945, a number of major changes have been introduced. Firstly, the different health-care funds (there are five: General, Independent, Agricultural, Student, Public Servants) now all reimburse at the same rate. Secondly, since 2000, the government now provides health care to those who are not covered by a mandatory regime (those who have never worked and who are not students, meaning the very rich or the very poor). This regime, unlike the worker-financed ones, is financed via general taxation and reimburses at a higher rate than the profession-based system for those who cannot afford to make up the difference. Finally, to counter the rise in health-care costs, the government has installed two plans, (in 2004 and 2006), which require insured people to declare a referring doctor in order to be fully reimbursed for specalist visits, and which installed a mandatory co-pay of 1 € (about $1.45) for a doctor visit, 0,50 € (about 80 ¢) for each box of medicine prescribed, and a fee of 16-18 € (20-25 $) per day for hospital stays and for expensive procedures.

An important element of the French insurance system is solidarity: the more ill a person becomes, the less they pay. This means that for people with serious or chronic illnesses, the insurance system reimburses them 100 % of expenses, and waives their co-pay charges.

Finally, for fees that the mandatory system does not cover, there is a large range of private complementary insurance plans available. The market for these programs is very competitive, and often subsidised by the employer, which means that premiums are usually modest. 85% of French people benefit from complementary private health insurance.

Netherlands

In 2006, a new system of health insurance came into force in the Netherlands. This new system avoids the two pitfalls of adverse selection and moral hazard associated with traditional forms of health insurance by using a combination of regulation and an insurance equalization pool. Moral hazard is avoided by mandating that insurance companies provide at least one policy which meets a government set minimum standard level of coverage, and all adult residents are obliged by law to purchase this coverage from an insurance company of their choice. All insurance companies receive funds from the equalization pool to help cover the cost of this government-mandated coverage. This pool is run by a regulator which collects salary-based contributions from employers, which make up about 50% of all health care funding, and funding from the government to cover people who cannot afford health care, which makes up an additional 5%.

The remaining 45% of health care funding comes from insurance premiums paid by the public, for which companies compete on price, though the variation between the various competing insurers is only about 5%. However, insurance companies are free to sell additional policies to provide coverage beyond the national minimum. These policies do not receive funding from the equalization pool, but cover additional treatments, such as dental procedures and physiotherapy, which are not paid for by the mandatory policy.

Funding from the equalization pool is distributed to insurance companies for each person they insure under the required policy. However, high-risk individuals get more from the pool, and low-income persons and children under 18 have their insurance paid for entirely. Because of this, insurance companies no longer find insuring high risk individuals an unappealing proposition, avoiding the potential problem of adverse selection.

Insurance companies are not allowed to have co-payments, caps, or deductibles, or to deny coverage to any person applying for a policy, or to charge anything other than their nationally set and published standard premiums. Therefore, every person buying insurance will pay the same price as everyone else buying the same policy, and every person will get at least the minimum level of coverage.

United Kingdom

The UK's National Health Service (NHS) is a publicly funded healthcare system that provides coverage to everyone normally resident in the UK. It is not strictly an insurance system because (a) there are no premiums collected, (b) costs are not charged at the patient level and (c) costs are not pre-paid from a pool. However, it does achieve the main aim of insurance which is to spread financial risk arising from ill-health. The costs of running the NHS (est. £104 billion in 2007-8) are met directly from general taxation. The NHS provides the majority of health care in the UK, including primary care, in-patient care, long-term health care, ophthalmology and dentistry.

Private health care has continued parallel to the NHS, paid for largely by private insurance, but it is used by less than 8% of the population, and generally as a top-up to NHS services. There are many treatments that the private sector does not provide. For example, health insurance on pregnancy is generally not covered or covered with restricting clauses. One of the major insurers, BUPA, excludes many forms of treatment and care that most people will need during their lifetime or specialist care most of which are freely available from the NHS. These include:

ageing, menopause and puberty; AIDS/HIV; allergies or allergic disorders; birth control, conception, sexual problems and sex changes; chronic conditions; complications from excluded or restricted conditions/ treatment; convalescence, rehabilitation and general nursing care ; cosmetic, reconstructive or weight loss treatment; deafness; dental/oral treatment (such as fillings, gum disease, jaw shrinkage, etc); dialysis; drugs and dressings for out-patient or take-home use† ; experimental drugs and treatment; eyesight; HRT and bone densitometry; learning difficulties, behavioural and developmental problems; overseas treatment and repatriation; physical aids and devices; pre-existing or special conditions; pregnancy and childbirth; screening and preventive treatment; sleep problems and disorders; speech disorders; temporary relief of symptoms. BUPA's competitors include, among others, AXA, Aviva, Groupama Healthcare and Pru Health.

Recently the private sector has been used to increase NHS capacity despite a large proportion of the British public opposing such involvement. According to the World Health Organization, government funding covered 86% of overall health care expenditures in the UK as of 2004, with private expenditures covering the remaining 14%.

United States

Main articles: Health insurance in the United States, Health insurance reform, and Health care in the United States

The United States mixed economy health care system relies heavily on private (for profit) and not-for-profit health insurance, which is the primary source of coverage for most Americans. According to the United States Census Bureau, approximately 84% of Americans have health insurance; some 60% obtain it through an employer, while about 9% purchase it directly. Various government agencies provide coverage to about 27% of Americans (there is some overlap in these figures).

Public programs provide the primary source of coverage for most seniors citizens and for low-income children and families who meet certain eligibility requirements. The primary public programs are Medicare, a federal social insurance program for seniors and certain disabled individuals, Medicaid, funded jointly by the federal government and states but administered at the state level, which covers certain very low income children and their families, and SCHIP, also a federal-state partnership that serves certain children and families who do not qualify for Medicaid but who cannot afford private coverage. Other public programs include military health benefits provided through TRICARE and the Veterans Health Administration and benefits provided through the Indian Health Service. Some states have additional programs for low-income individuals.

In 2006, there were 47 million people in the United States (16% of the population) who were without health insurance for at least part of that year. About 37% of the uninsured live in households with an income over $50,000.

In 2004, U.S. health insurers directly employed almost 470,000 people at an average salary of $61,409. (As of the fourth quarter of 2007, the total U.S. labor force stood at 153.6 million, of whom 146.3 million were employed. Employment related to all forms of insurance totaled 2.3 million. Mean annual earnings for full-time civilian workers as of June 2006 were $41,231; median earnings were $33,634.) The insurance industry also represents a significant lobbying group in the United States. For 2008 insurance was the 8th among industries in political contributions to members of Congress, giving $28,654,121, of which 51% was given to Democrats and 49% to Republicans, with the top recipient of insurance industry contributions being Senator John McCain (R-AZ). The leading contributor from the insurance industry — as measured by total political contributions — was AFLAC, Inc., which contributed $907,150 in 2007.

Health Insurance

Health insurance is insurance that pays for medical expenses. It is sometimes used more broadly to include insurance covering disability or long-term nursing or custodial care needs. It may be provided through a government-sponsored social insurance program, or from private insurance companies. It may be purchased on a group basis (e.g., by a firm to cover its employees) or purchased by individual consumers. In each case, the covered groups or individuals pay premiums or taxes to help protect themselves from high or unexpected healthcare expenses. Similar benefits paying for medical expenses may also be provided through social welfare programs funded by the government.

By estimating the overall risk of healthcare expenses, a routine finance structure (such as a monthly premium or annual tax) can be developed, ensuring that money is available to pay for the healthcare benefits specified in the insurance agreement. The benefit is administered by a central organization such as a government agency, private business, or not-for-profit entity.

History and evolution

The concept of health insurance was proposed in 1694 by Hugh the Elder Chamberlen from the Peter Chamberlen family. In the late 19th century, "accident insurance" began to be available, which operated much like modern disability insurance. This payment model continued until the start of the 20th century in some jurisdictions (like California), where all laws regulating health insurance actually referred to disability insurance.

Accident insurance was first offered in the United States by the Franklin Health Assurance Company of Massachusetts. This firm, founded in 1850, offered insurance against injuries arising from railroad and steamboat accidents. Sixty organizations were offering accident insurance in the U.S. by 1866, but the industry consolidated rapidly soon thereafter. While there were earlier experiments, the origins of sickness coverage in the U.S. effectively date from 1890. The first employer-sponsored group disability policy was issued in 1911.

Before the development of medical expense insurance, patients were expected to pay all other health care costs out of their own pockets, under what is known as the fee-for-service business model. During the middle to late 20th century, traditional disability insurance evolved into modern health insurance programs. Today, most comprehensive private health insurance programs cover the cost of routine, preventive, and emergency health care procedures, and most prescription drugs, but this was not always the case.

Hospital and medical expense policies were introduced during the first half of the 20th century. During the 1920s, individual hospitals began offering services to individuals on a pre-paid basis, eventually leading to the development of Blue Cross organizations. The predecessors of today's Health Maintenance Organizations (HMOs) originated beginning in 1929, through the 1930s and on during World War II.

How it works

A health insurance policy is a contract between an insurance company and an individual or his sponsor (e.g. an employer). The contract can be renewable annually or monthly. The type and amount of health care costs that will be covered by the health insurance company are specified in advance, in the member contract or "Evidence of Coverage" booklet. The individual insured person's obligations may take several forms:

• Premium: The amount the policy-holder or his sponsor (e.g. an employer) pays to the health plan each month to purchase health coverage.
• Deductible: The amount that the insured must pay out-of-pocket before the health insurer pays its share. For example, a policy-holder might have to pay a $500 deductible per year, before any of their health care is covered by the health insurer. It may take several doctor's visits or prescription refills before the insured person reaches the deductible and the insurance company starts to pay for care.
• Copayment: The amount that the insured person must pay out of pocket before the health insurer pays for a particular visit or service. For example, an insured person might pay a $45 co-payment for a doctor's visit, or to obtain a prescription. A co-payment must be paid each time a particular service is obtained.
• Coinsurance: Instead of, or in addition to, paying a fixed amount up front (a co-payment), the co-insurance is a percentage of the total cost that insured person may also pay. For example, the member might have to pay 20% of the cost of a surgery over and above a co-payment, while the insurance company pays the other 80%. If there is an upper limit on coinsurance, the policy-holder could end up owing very little, or a great deal, depending on the actual costs of the services they obtain.
• Exclusions: Not all services are covered. The insured person is generally expected to pay the full cost of non-covered services out of their own pocket.
• Coverage limits: Some health insurance policies only pay for health care up to a certain dollar amount. The insured person may be expected to pay any charges in excess of the health plan's maximum payment for a specific service. In addition, some insurance company schemes have annual or lifetime coverage maximums. In these cases, the health plan will stop payment when they reach the benefit maximum, and the policy-holder must pay all remaining costs.
• Out-of-pocket maximums: Similar to coverage limits, except that in this case, the insured person's payment obligation ends when they reach the out-of-pocket maximum, and the health company pays all further covered costs. Out-of-pocket maximums can be limited to a specific benefit category (such as prescription drugs) or can apply to all coverage provided during a specific benefit year.
• Capitation: An amount paid by an insurer to a health care provider, for which the provider agrees to treat all members of the insurer.
• In-Network Provider: (U.S. term) A health care provider on a list of providers pre-selected by the insurer. The insurer will offer discounted coinsurance or co-payments, or additional benefits, to a plan member to see an in-network provider. Generally, providers in network are providers who have a contract with the insurer to accept rates further discounted from the "usual and customary" charges the insurer pays to out-of-network providers.
• Prior Authorization: A certification or authorization that an insurer provides prior to medical service occurring. Obtaining an authorization means that the insurer is obligated to pay for the service, assume it matches what was authorized. Many smaller, routine services do not require authorization.
• Explanation of Benefits: A document sent by an insurer to a patient explaining what was covered for a medical service, and how they arrived at the payment amount and patient responsibility amount.

Prescription drug plans are a form of insurance offered through some employer benefit plans in the U.S., where the patient pays a co-payment and the prescription drug insurance part or all of the balance for drugs covered in the formulary of the plan.

Some, if not most, health care providers in the United States will agree to bill the insurance company if patients are willing to sign an agreement that they will be responsible for the amount that the insurance company doesn't pay. The insurance company pays out of network providers according to "reasonable and customary" charges, which may be less than the provider's usual fee. The provider may also have a separate contract with the insurer to accept what amounts to a discounted rate or capitation to the provider's standard charges. It generally costs the patient less to use an in-network provider.

Health plan vs. health insurance

Historically, HMOs tended to use the term "health plan", while commercial insurance companies used the term "health insurance". A health plan can also refer to a subscription-based medical care arrangement offered through HMOs, preferred provider organizations, or point of service plans. These plans are similar to pre-paid dental, pre-paid legal, and pre-paid vision plans. Pre-paid health plans typically pay for a fixed number of services (for instance, $300 in preventive care, a certain number of days of hospice care or care in a skilled nursing facility, a fixed number of home health visits, a fixed number of spinal manipulation charges, etc.) The services offered are usually at the discretion of a utilization review nurse who is often contracted through the managed care entity providing the subscription health plan. This determination may be made either prior to or after hospital admission (concurrent utilization review).

Comprehensive vs. scheduled

Comprehensive health insurance pays a percentage of the cost of hospital and physician charges after a deductible (usually applies to hospital charges) or a co-pay (usually applies to physician charges, but may apply to some hospital services) is met by the insured. These plans are generally expensive because of the high potential benefit payout — $1,000,000 to 5,000,000 is common — and because of the vast array of covered benefits.

Scheduled health insurance plans are not meant to replace a traditional comprehensive health insurance plans and are more of a basic policy providing access to day-to-day health care such as going to the doctor or getting a prescription drug. In recent years, these plans have taken the name mini-med plans or association plans. These plans may provide benefits for hospitalization and surgical, but these benefits will be limited. Scheduled plans are not meant to be effective for catastrophic events. These plans cost much less than comprehensive health insurance. They generally pay limited benefits amounts directly to the service provider, and payments are based upon the plan's "schedule of benefits". Annual benefits maximums for a typical scheduled health insurance plan may range from $1,000 to $25,000.